Provider Demographics
NPI:1700985496
Name:AVERY, ROBERT LOGAN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LOGAN
Last Name:AVERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E MICHELTORENA ST STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93103-4211
Mailing Address - Country:US
Mailing Address - Phone:805-963-1648
Mailing Address - Fax:805-965-5214
Practice Address - Street 1:525 E MICHELTORENA ST STE A
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93103-4211
Practice Address - Country:US
Practice Address - Phone:805-963-1648
Practice Address - Fax:805-965-5214
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52052207WX0107X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
180038771Medicare PIN
00A520520Medicare ID - Type Unspecified
WA52052GMedicare ID - Type Unspecified
WA52052HMedicare ID - Type Unspecified
WA52052IMedicare ID - Type Unspecified
WA52052JMedicare ID - Type Unspecified
E91137Medicare UPIN